AcuYoga^™ Initial Intake Form

Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session.

I understand that the acupuncture and/or laser treatment sessions I receive are provided for the basic purpose of relaxation, ease symptoms and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner, so that the pressure and/or treatments may be adjusted to my level of comfort. I further understand that my treatments at RESET Health/The Acupuncture Studio should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician or other qualified medical specialist for any mental or physical ailment. I understand that the practitioner is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. I understand that bruising and tenderness can result from my sessions and may cause my body to detoxify, such symptoms may include, but not limited to body aches, drowsiness, etc. I also understand the effectiveness of my sessions may cause my motor reaction and alertness to be affected, hence I agree not to leave premise until I am fully alert and conscious of my action and understand that there shall be no liability on the practitioner part should I fail to do so.

Because acupuncture and laser therapy should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioners part should I fail to do so. I give permission for the practitioners to discuss my medical history for the purpose of my treatment sessions.

If at any time during the class, you feel discomfort or strain, gently come out of the posture. You may rest at any time during the class. It is important in yoga that you listen to your body, and respect its limits on any given day. I, the undersigned, understand that yoga is not a substitute for medical attention, examination, diagnosis, or treatment. I should consult a physician prior to beginning any activity program, including yoga. I recognize that it is my responsibility to notify my teacher of any serious illness or injury before every yoga class. I will not perform any postures to the extent of strain or pain. I accept that neither the instructor, nor the hosting facility, is liable for any injury, or damages, to person or property, resulting from the taking of the class. Those under 18 years of age must have this form signed by a parent or guardian.